What is the treatment plan for a 5-year-old male with a penetrating eye injury (POKI) presenting with bleeding and redness after poking his eye?

Management of Eye Injury in a 5-Year-Old with Bleeding and Redness

A 5-year-old male with bleeding and redness after poking his eye requires immediate ophthalmologic evaluation to rule out globe injury or sight-threatening conditions.

Initial Assessment and Stabilization

Red Flag Assessment

Assess for the following red flags that require emergency ophthalmology referral within 24 hours 1:

• Redness (unilateral or bilateral)
• Visual acuity loss
• Pain (moderate to severe)
• Intolerance to light
• Damage to cornea (visible ulceration, haze, opacity)

Immediate Examination

1. Visual acuity testing (if possible with child's cooperation)
2. Pupillary assessment for relative afferent pupillary defect
3. External examination for:
   • Eyelid lacerations or malfunction
   • Visible foreign bodies
   • Extent of bleeding
4. Slit-lamp examination (if available and child cooperates) to assess:
   • Corneal integrity
   • Anterior chamber for hyphema (blood in anterior chamber)
   • Pupil and iris abnormalities 1

Emergency Management

For Toxic/Chemical Eye Injury

If chemical exposure is suspected:

• Immediately rinse eye with copious amounts of tap water for at least 15 minutes
• If tap water unavailable, use normal saline or commercial eye irrigation solution 1

For Bleeding/Trauma

• Apply gentle direct pressure to control external bleeding (avoid pressure on the globe itself)
• Cold therapy with ice pack may be useful for periorbital injuries, but use with caution in children due to hypothermia risk 1

Treatment Algorithm

Scenario 1: Suspected Globe Penetration or Perforation

Signs include:

• Irregular pupil
• Visible laceration of cornea or sclera
• Hyphema (blood in anterior chamber)
• Shallow anterior chamber

Management:

1. Do NOT apply pressure to the eye
2. Shield the eye with a protective cover (paper cup or eye shield)
3. No eye drops or ointments
4. NPO status (in case emergency surgery is needed)
5. Immediate ophthalmology referral/transfer to emergency department 1, 2

Scenario 2: Corneal Abrasion/Foreign Body

Signs include:

• Pain, tearing, photophobia
• Foreign body sensation
• Visible scratch or foreign material

Management:

1. Topical antibiotic ointment or drops
2. Consider cycloplegic drops for comfort
3. Ophthalmology follow-up within 24-48 hours 3

Scenario 3: Subconjunctival Hemorrhage

Signs include:

• Bright red blood under conjunctiva
• No pain
• Normal vision

Management:

1. Reassurance
2. Artificial tears for comfort
3. Follow-up if not resolving within 2 weeks 4

Important Considerations

High-Risk Factors

Studies show that high-velocity mechanism injuries are significantly associated with poor visual outcomes, even when initial visual acuity appears normal 2. Therefore, urgent ophthalmologic consultation is recommended for:

• Any penetrating injury
• High-velocity mechanism of injury
• Visible blood in anterior chamber (hyphema)
• Abnormality of pupil or uvea 5

Age-Specific Considerations

In children under 7 years, visual development pathways still have plasticity, making prompt treatment critical to prevent amblyopia 1. Children may be uncooperative for examination, necessitating:

• Examination under sedation if complete assessment isn't possible
• Creative approaches to visual acuity testing appropriate for age 4

Follow-up Care

1. Short-term follow-up: 24-48 hours for most eye injuries
2. Warning signs to return immediately:
   • Worsening pain
   • Decreased vision
   • Increased redness or discharge
   • New floaters or flashes of light 1

Prevention Counseling

1. Advise parents about age-appropriate toys and activities
2. Recommend protective eyewear for sports and activities
3. Educate about proper supervision during play with pointed objects 6

Remember that penetrating eye injuries are common in young males and can result in poor visual outcomes if not properly managed 5. When in doubt, refer to ophthalmology, as normal visual acuity at presentation is not reassuring in high-velocity or penetrating injuries 2.